1
CMS and ONC: Enabling Data Interoperability
Across the Continuum
Session 101, February 13, 2019
Elizabeth Palena Hall, ONC; Beth Connor, CMS
Michelle Dougherty, RTI International; Dave Hill, MITRE
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Conflict of Interest
Elizabeth Palena Hall, ONC
• Has no real or apparent conflicts of interest to report.
Beth Connor, CMS
• Has no real or apparent conflicts of interest to report.
Michelle Dougherty, RTI International
• Has no real or apparent conflicts of interest to report.
Dave Hill, MITRE
• Has no real or apparent conflicts of interest to report.
3
Disclaimer
This presentation was current at the time it was published or uploaded
onto the web. Medicare policy changes frequently so links to the source
documents have been provided within the document for your reference.
This presentation was prepared as a service to the public and is not
intended to grant rights or impose obligations. This presentation may
contain references or links to statutes, regulations, or other policy
materials. The information provided is only intended to be a general
summary. It is not intended to take the place of either the written law or
regulations. We encourage readers to review the specific statutes,
regulations, and other interpretive materials for a full and accurate
statement of their contents.
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Agenda
• The patient story and value of post-acute care interoperable
exchange across the continuum
• IMPACT Act and CMS Data Element Library
• Advancing interoperability by aligning assessment content with
industry standards and mapping content to vocabularies,
terminologies and code sets
• Health Data Exchange through FHIR
• Conclusion and Q&A
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Objectives
• Describe the CMS approach for development and implementation of
the CMS Data Element Library.
• Describe how various users can utilize the CMS DEL functionality
including search and reports.
• Define the goals of standardized CMS assessment content mapped to
HIT vocabularies and exchange standards.
• Discuss the strategies and use cases for how assessment content can
be re-used to support discharge planning, quality improvement, and
reduce burden through interoperable health information exchange.
• Explore how the emerging FHIR standards can be used to enable
exchange among providers and with patients and their care givers.
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Acronyms in this Presentation
• CMS – Centers for Medicare & Medicaid Services
• CCD – Continuity of Care Document
• C-CDA – HL7 Consolidated Clinical Document Architecture
• CCDS – Common Clinical Data Set
• DCPAC – Division of Chronic and Post-Acute Care
• DEL – Data Element Library
• FHIR – Fast Healthcare Interoperability Resources
• HHA – Home Health Agency
• HIS – Hospice Item Set
• HIT – Health Information Technology
• HL7 – Health Level 7
• IMPACT – Improving Medicare Post-Acute Care Transformation Act
• IRF – Inpatient Rehabilitation Facility
• IRF-PAI – Inpatient Rehabilitation Facility Patient Assessment
Instrument
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Acronyms in this Presentation (Cont.)
• ISA – ONC Interoperability Standards Advisory
• LCDS – Long-Term Care Hospital (LTCH) Continuity Assessment
Record and Evaluation (CARE) Data Set
• LOINC – Logical Observation Identifiers Names and Codes
• LTCH – Long-Term Care Hospital
• MDS – Minimum Data Set
• OASIS – Outcome and Assessment Information Set
• ONC – Office of the National Coordinator for Health IT
• PAC – Post-Acute Care
• RELMA -- Regenstrief LOINC Mapping Assistant
• SNF – Skilled Nursing Facility
• SNOMED-CT – Systematized Nomenclature of Medicine - Clinical Terms
• SPADEs – Standardized Patient Assessment Data Elements
• USCDI -- U.S. Core Data for Interoperability
• VSAC – Value Set Authority Center
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The patient story and value of post-acute
care interoperable exchange across the
continuum
9
The Patient Story
Ms. Smith
Psychiatric Hospital
Hospital A
Skilled Nursing Facility
Inst. Pharmacy
Hospital B
Home Health
Primary Care
Provider
MDS OASIS
Dialysis Center
FASI
Ms. Smith Daughter
EMS
Home and Community
Based Services
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Why is Post-Acute Care
Important?
PAC Setting
Long
-
term Care Hospitals (LTCH)
Skilled Nursing Facilities (SNF)
Home Health Agencies (HHA)
Inpatient Rehabilitation Facilities
(IRF)
Hospices
• Approximately 33,000 PAC
Providers in the U.S.
• Almost 45% of Medicare
hospital discharges are
followed by PAC use
(1)
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Episodes Requiring PAC Services
after an Acute Hospitalization
No Services
55%
PAC
Services
45%
MEDICARE BENEFICIARIES REQUIRING PAC
SERVICES AFTER AN ACUTE HOSPITALIZATION IN
2014
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The Most Frequent Sequences of Care
Acute
Hospitalization
HHA
SNF
HHA HHA
SNF HHA
42.9%
18.2%
7.5%
6%
Physicians and specialists also coordinate
on-going care with PAC settings.
Source: http://www.medpac.gov/docs/default-source/contractor-reports/sept2018_pac_sequence_of_care_w_cov_contractor_sec.pdf?sfvrsn=0
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Volume of Claims by Chronic
Conditions in 2016
Source: 2016 Medicare Claims Data
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ONC Data Brief: SNF & HHA EHR
Adoption and Interoperability in 2017
EHR
78%*
No
EHR
22%
HHA
EHR
66%
No
EHR
34%
SNF
• EHR adoption rates were higher among HHAs compared to SNFs in 2017
• HHAs are more likely than SNFs to engage in each domain of interoperability.
41%*
52%*
53%*
36%*
55%*
27%
41% 41%
18%
48%
Find Send Receive Integrate Outside Info
Available
HHA SNF
Source: https://www.healthit.gov/sites/default/files/page/2018-11/Electronic-Health-Record-Adoption-and-Interoperability-among-U.S.-Skilled-Nursing-Facilities-and-Home-Health-Agencies-in-2017.pdf
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Interoperability Challenges
• Lack of business case
– Revenue levels (e.g. HITECH), what can they invest in IT?
– No financial incentives to cover PACs
– Economic motivation for interoperability needed
• Lack of standards or consistent use of standards
– Use of standards varies across HIEs
– Different parts of healthcare address overlapping things differently
• Limited understanding of interoperability and its value
– Lots of education needed (efficiency gains, improvements in care quality, etc.)
– Even with advanced tools, lots of paper still exchanged
• Lack of formalized workflows
– What needs to be done when data arrives?
– Using 10 different ways to discharge a patient
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Interoperability Challenges (cont. 1)
• Frequent changes to payment models diverts resources from
investment in interoperability
– Vendors have divert resources to update software
– Providers have divert resources to purchase updates
• Meeting CMS regulatory requirements diverts resources from
investment in interoperability
– Regulation focus takes resources away from health IT
• Lack of data transparency
– What data is available and from where?
• Data exchange between EHR systems is poor
– Interoperability across different versions of same EHR and between
different EHRs is problematic
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Interoperability Challenges (cont. 2)
• Staff recruiting and retention in PAC facilities
– Decreasing Medicare reimbursements, competing with private industry (e.g.
Amazon), training costs, 30-40% attrition in SNFs
• Accessibility is problematic for some patients
– Portals, username/password challenging for mentally-challenged
• Working physicians are not involved enough in standards development
and software design
– EHRs are difficult to use and burden clinicians
– Many involved clinical SMEs lack recent experience with patients
• Senior housing facilities do not employ any health IT infrastructure
– Senior housing facilities consider themselves landlords
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Interoperability Challenges (cont. 3)
• Assisted living facilities have been slow to adopt EHRs
– Frailty and complexity of medications tracking/management
• Post-acute utilization is high and increasing
– Focus on reducing length of stay in hospitals increases post-acute
usage
• Internet connectivity for some health facilities is poor
– Small and rural providers need representation
• Patient matching is difficult, inaccurate, and hard to automate
– Algorithms exist, but manual matching is still required
• Data provided by ambulatory care are not timely
– Data frequently not available to PAC facilities when needed
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Points of Failure
• Poor communication across care providers, including outpatient
– Medication discrepancies such as drug omissions during transitions of
care are common
– Multiple modes of information transmission are often used
– Delays in PAC services can lead to adverse events and preventable
readmissions
– Redundant information collection creates inefficiencies and burden
• Reliance on patient recall during periods of high stress
– Recall of information can be unreliable
– Increased patient / family stress
• Increased Cost and Provider Burden
– Additional costs related to hospital stays from adverse events,
readmissions
– Additional administrative costs to locate, reconcile and coordinate
information
– Longer length of stays and higher resource utilization
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Potential Cost Savings related to Points
of Failures
Description
Financial Cost
Time PCP spends collecting information, faxing and re
-faxing or sending information
through another mode (1 hour of time)
$107 *
Average cost of adverse event during a hospital stay
$13,745 #
Average Cost of a Home Health Agency Stay
$3,040 †
Average Cost of an Inpatient Rehabilitation Facility Stay
$19,714 †
Average Cost of a Skilled Nursing Facility stay
$18,174 †
Average Cost of a Long
-Term Care Hospital stay $40,656 †
* https://www.medscape.com/slideshow/2018-compensation-overview-6009667#2
# L Levinson DR. Washington, DC: US Department of Health and Human Services, Office of the Inspector General;
November 2010. Report No. OEI-06-09-00090
† MedPAC, A Data Book: Health care spending and the Medicare program, June 2018
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IMPACT Act and CMS Data Element Library
(DEL)
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IMPACT Act of 2014
• Bi-partisan bill passed on September 18, 2014, and signed into
law October 6, 2014
• The Act requires standardized patient assessment data elements
for:
– Long-term Care Hospitals (LTCHs)
– Skilled Nursing Facilities (SNFs)
– Home Health Agencies (HHAs)
– Inpatient Rehabilitation Facilities (IRFs)
• The Act specifies that data “… be standardized and
interoperable so as to allow for the exchange of such data
among such post-acute care providers and other providers
and the use by such providers of such data that has been so
exchanged, including by using common standards and
definitions in order to provide access to longitudinal
information for such providers to facilitate coordinated care
and improved Medicare beneficiary outcomes…”.
Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014
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Data Element Interoperability
• IMPACT Act requires that post-acute care assessment data elements
be interoperable to:
• “allow for the exchange of data among PAC providers and other
providers and the use by such providers of such data that has been
exchanged, including by using common standards and definitions, in order
to provide access to longitudinal information for such providers to
facilitate coordinated care and improved Medicare beneficiary
outcomes.”
• Interoperable data elements facilitate improvements to reduce overall
provider burden by allowing the use and exchange of healthcare data
• Supports provider exchange of electronic health information to
facilitate care coordination and person-centered care
• Supports real-time, data driven, clinical decision making
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IMPACT Act Requirements
Data Must be Interoperable
• Quality Measures
– Functional Status
– Skin Integrity
– Medication Reconciliation
– Incidence of Major Falls
– Transfer of Health
Information
• Resource Use and Other
Measures
– Medicare Spending per
Beneficiary
– Discharge to Community
– Potentially Preventable
Hospital Readmissions
• Standardized Data
Submission
– Admission and Discharge
– Functional status
– Cognitive function and
mental status
– Special services,
treatments, and
interventions
– Medical conditions and
co-morbidities
– Impairments
– Other categories required
by the Secretary
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Post-Acute Care Assessments
OASIS C2
CMS PAC
Assessments
LTCH Continuity
Assessment
Record
& Evaluation (CARE)
Data Set (LCDS)
Resident
Assessment
Instrument
(RAI)
Minimum Data Set
(MDS)
Outcome and
Assessment
Information Set
(OASIS)
IRF Patient
Assessment
Instrument (IRFPAI)
Hospice Item Set
(HIS)
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PAC Assessment Content
• Administrative Content
– Patient Name
– Date of Birth
– Race/Ethnicity
– Marital status
– Admission/Discharge dates
– Admit from/Discharged to locations
– Reason for admission
– Provider NPI, CCN, Medicaid Provider #
• Standardized Patient Assessment
Data Elements (SPADEs) across
instruments
– Function (e.g., self care and mobility)
– Cognitive function (e.g., express &
understand ideas; mental status, such as
depression and dementia)
– Special services, treatments &
interventions (e.g., need for ventilator,
dialysis, chemotherapy, and total
parenteral nutrition)
– Medical conditions and co-morbidities
(e.g., diabetes, heart failure, and pressure
ulcers)
– Impairments (e.g., incontinence; impaired
ability to hear, see, or swallow)
– Other categories
• Clinical Content
– Diagnosis/medical conditions
– Mental/Cognitive Status (memory,
orientation, consciousness, delirium,
mood, behavior)
– Communication (express needs,
understanding verbal/non-verbal content,
hearing and vision)
– Functional Status (Self-care/ADLs,
Mobility, Use of assistive devices)
– Bladder and Bowel continence
– Falls
– Pressure ulcers and other skin conditions
– Surgery
– Nutritional and swallowing status
– Medication information
– Special treatments, procedures &
programs
– Height and Weight
– Patient preferences and goals of
treatment
– Pain
– Vaccinations
– Therapy- PT, OT, SLT
– Living arrangements/support availability
– Care planning
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SPADES: Standardized Assessment:
Many Uses
Payment
Data Elements: Question and Response
QI
Care Planning/
Decision Support
Quality
Reporting
Care
Transitions
29
The Data Element Library (DEL)
• The DEL is a centralized resource for CMS assessment data
elements (e.g. questions and response options), and their
related mappings to nationally accepted health IT standards
DEL Contents
Assessment and version (e.g., MDS
3.0 v. 1.16)
Item label (e.g.- GG0170)
Item status (Published, Active,
Inactive)
Copyright information (if applicable)
CMS usage (Payment, Quality
Measure, Survey and Certification,
etc.)
Identification of skip pattern triggers
and lookback periods
Health IT standards (e.g., LOINC,
SNOMED)
Visit the DEL here: https://del.cms.gov
PAC Setting CMS Assessment
Long
-
term Care Hospitals (LTCHs)
LTCH Continuity Assessment
Record & Evaluation (CARE) Data
Set (LCDS)
Skilled Nursing Facilities (SNFs)
Resident Assessment Instrument
(RAI) Minimum Data Set (MDS)
Home Health Agencies (HHAs)
Outcome and Assessment
Information Set (OASIS)
Inpatient Rehabilitation Facilities
(IRFs)
IRF patient assessment instrument
(IRF
-PAI)
Hospices
Hospice Item Set
31
Search Categories
32
Search Results List
33
Detailed Data Element Information
34
OASIS D Health IT Codes
35
Trainings/FAQs
36
Alignment and Interoperability: Advancing
interoperability by aligning assessment
content with industry standards and
mapping content to vocabularies,
terminologies and code sets
37
Guiding Principle: Data Needs to
Follow the Person
Support data availability in real-time. Electronic information is exchanged
and used by health IT systems without special effort on the part of the
user.
38
Making PAC Assessment Data Elements
Standardized/Aligned and Interoperable
Relevant interoperable
assessment data (such
as functional status,
cognitive status, etc.)
can be used to populate
documents
39
CMS Data Element Library HIT
Workgroup Focus
Vision for
Interoperable
Assessment
Content
Aligning with
National
Standards
Mapping to
Relevant
Vocabulary &
Terminology
Standards
Use of
Interoperable
Assessment
Content by
Implementers
Opportunities for
Burden Reduction
Use Cases for
Interoperable
Assessment
Content
40
Vision for Interoperable Assessment
Content
• Strategy: Leverage standardized data that is
collected on almost all PAC patients to advance
interoperability, reduce burden, and improve patient
care.
• Models:
• Identify single code to represent the
assessment question and response and re-
use data in relevant exchange documents
(current focus)
• Identify a value set of codes that could be
used to support completion of an assessment
item (future)
41
Opportunities for Burden Reduction
and Improved Communication
• Real-time data availability improves patient care
• Machine processable data reduces provider burden:
– Eliminates duplicative data entry
– Minimizes searching medical record for relevant content
• Experiences of Early Adopters - Faster Data Entry
– Valuable to have common data standards across provider
types
– Data from exchange documents (e.g. CCD) populates the
patient record
42
Use Cases for Interoperable
Assessment Content
• Care coordination between multiple
providers / proxy / family members
– Appointments, readmissions,
sharing care plan, chart sharing,
transportation
• Transitions of care referrals
– Intake, info queries, transition out,
follow-up activity coordination
– Medication reconciliation
– Clinical decision support
• Admission / Discharge information
notifications
– Helps all parties to track patient
status
• Population Health Management
Administration
– Quality management, at risk
dollars, who is high risk and
why
• Changing relationship between
patient and caregivers
– Connective devices, patient
engagement, monitoring,
telehealth
• Getting providers engaged
– Quality compared to peers,
financial metrics, cost of care
• Advanced directives
– Sharing and notifications
43
Aligning with National Standards
• ONC Interoperability Standards Advisory
• DEL health IT standards align with
national policy
• LOINC and SNOMED-CT for assessment content
• Analyzed Common Clinical Data Set/U.S. Core Data for
Interoperability (USCDI)
• Identified opportunities for alignment of assessment content to
USCDI
• Provided comments on future candidate data types important to
support PAC for USCDI expansion
• 2019 ONC Interoperability Standards Advisory: https://www.healthit.gov/isa/sites/isa/files/inline-
files/2019ISAReferenceEdition.pdf
• ONC Common Clinical Data Set: https://www.healthit.gov/public-course/interoperability-basics-
training/lsn1069/010110---a.htm
• Draft USCDI: https://www.healthit.gov/sites/default/files/draft-uscdi.pdf
44
Mapping to Relevant Vocabulary &
Terminology Standards
• Selected codes aligned with national policy and
utilized in exchange standards (e.g. C-CDA templates)
• Mapped assessment content to LOINC and SNOMED
• LOINC codes represent the question and answer
• SNOMED codes represent the answer meaning
• LOINC codes are available for PAC assessments on the DEL
GG0100 as Shown on IRF-PAI
45
Use of Interoperable Assessment
Content by Implementers
• Best practices for data element design to support
interoperability
• Ensure health IT content vocabularies Use in HIE standards
• Leverage DEL’s content with other industry tools such as:
• Value Set Authority Center (VSAC)
• Regenstrief LOINC Mapping Assistant (RELMA)
• Convene Advisory Group (industry and HHS)
• Input on future direction for DEL and health IT priorities
• Identify priority use cases that leverage existing
standards and address gaps. Tailor implementation
guides and coordinate testing.
46
Industry Expert Roundtable on CMS
Data Element Library
• Provided feedback
on the CMS Data
Element Library:
– Inform healthcare
policies
– Advance
interoperability
– Support transfer
of care,
coordination of
care, quality
measurement,
and research
Suggested clarifying scope of DEL and how it
should be used by stakeholders; Ideas for future
development.
Identified priority use cases for transfer
summary and care planning; Suggested ways
the DEL to support outreach & testing.
Become a resource to connect industry standards
– align with other tools, identify/point to relevant
standards, fill gaps.
47
Health Data Exchange through FHIR
48
We’re Building the Future with FHIR
1) Participate with the right HL7 Working Groups
2) Create sustainable PAC Interoperability Working Group
3) Identify tightly-scoped use case to implement for a connect-a-
thon
4) Develop FHIR Implementation Guides for use case data
models
5) Review and harmonize FHIR Implementation Guides with
key stakeholders
6) Host connect-a-thon to test FHIR Implementation Guides
7) Build industry consensus around FHIR Implementation
Guides
8) Identify next agile part of use case to implement, and repeat
steps 4 through 8.
49
Outpatient → EMS → Inpatient →
Home Health
50
EMS → Inpatient → SNF
51
Proposed Timeline for FHIR Work
(Publish Dec 2019)
1 October 2018 31 March 2020
Nov 2018 Dec 2018 Jan 2019 Feb 2019 Mar 2019 Apr 2019 May 2019 Jun 2019 Jul 2019 Aug 2019 Sep 2019 Oct 2019 Nov 2019 Dec 2019 Jan 2020 Feb 2020 Mar 2020
LANDSCAPE ANALYSIS
Oct 2019
NEW FISCAL YEAR
Sep 2019
2019 WGM AND
CONNECTATHON
IN ATLANTA
28 Nov, 2018
TAG
GENERATE FHIR PROFILES
Mar 2019
PROJECT SCOPE STATEMENT
30 Jun, 2019
NOTICE OF INTENT TO
BALLOT - DEADLINE
Jul 2019
BALLOT CONTENT
Nov 2019
RECONCILIATION
Dec 2019
PUBLISH FHIR
IMPLEMENTATION
GUIDE
52
Proposed Timeline for FHIR Work
(Publish Mar 2020)
1 October 2018 31 March 2020
Nov 2018 Dec 2018 Jan 2019 Feb 2019 Mar 2019 Apr 2019 May 2019 Jun 2019 Jul 2019 Aug 2019 Sep 2019 Oct 2019 Nov 2019 Dec 2019 Jan 2020 Feb 2020 Mar 2020
LANDSCAPE ANALYSIS
27 Oct, 2019
NOTICE OF INTENT TO
BALLOT - DEADLINE
Oct 2019
NEW FISCAL YEAR
Nov 2019
BALLOT CONTENT
Jan 2020
JANUARY 2020
CONNECTATHON AND WGM
Sep 2019
2019 WGM AND
CONNECTATHON
IN ATLANTA
Mar 2020
RECONCILIATION
Mar 2020
PUBLISH FHIR
IMPLEMENTATION
GUIDE
28 Nov, 2018
TAG
GENERATE FHIR PROFILES
Mar 2019
PROJECT SCOPE STATEMENT
53
Call to Action: How to Participate
• Health IT developers
– Build on existing health
IT systems
– Try out new
projects/systems
• PAC providers
– Analyze how and where
assessment data fits in
clinical workflow
– Provide feedback on
development priorities
• Ways to contribute:
– Subject matter expertise
– Scalability of implementing
the eventual solution
– Assist in the delivery of key
deliverables and
project artifacts
– Development of testing
tools, testing
implementations, etc.
To participate in PAC Interoperability workgroup and FHIR
connect-a-thon contact: Dave Hill, dwhill@mitre.org
54
Wrap Up and Q&A
55
Resources
• For more information on the IMPACT Act, visit the IMPACT Act
webpage
• For more information on Post-Acute Care Quality Reporting
Programs, visit:
• Home Health Agencies
• Hospice Agencies
• Inpatient Rehab Facilities
• Long-term Care Hospitals
• Skilled Nursing Facilities
• For DEL updates, sign up for the listserv here
• For DEL feedback or questions, contact: DELHelp@cms.hhs.gov
56
Thank You
• Beth Connor, CMS
• Beth.Connor@cms.hhs.gov
• Elizabeth Palena Hall, ONC
• Elizabeth.PalenaHall@hhs.gov
• Michelle Dougherty, RTI International
• MDougherty@rti.org
• @mvldougherty
• Dave Hill, MITRE
• Dwhill@mitre.org
CMS
Contractors
supporting the
DEL:
NIC/Telligen
RTI International
MITRE
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